Chennai Spine Foundation is a registered non-governmental organisation (NGO) and non-profit organization (NPO) to support and guide children and adult patients with spinal problems to access appropriate care for improved quality of life.

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For Parents

For parents

Knowing your child has a spine condition like scoliosis or kyphosis typically raises many questions. Monitoring the progression of the deformity curve as your child grows raises even more concern. You can find practical explanations of a range of spine topics by exploring our Parents Portal.

Scoliosis:

Scoliosis is an abnormal lateral curvature of the spine. It is most often diagnosed in childhood or early adolescence. The spine’s normal curves occur at the cervical, thoracic and lumbar regions in the so-called “sagittal” plane. These natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement. Scoliosis is often defined as abnormal spinal curvature (S or C shaped) in the “coronal” (frontal) plane. While the degree of curvature is measured on the coronal plane, scoliosis is actually a more complex, three-dimensional problem which involves coronal, sagittal and axial planes.

Scoliosis affects 2-3 percent of the population. Scoliosis can be present at birth or develop in infancy or early childhood or adolescence. Scoliosis is broadly classified as Early Onset Scoliosis when scoliosis is present at birth or diagnosed before the age of 10 year or Late Onset Scoliosis when scoliosis develops after the age of 10 years (10-15 years). Scoliosis in children is also classified by age: 1.) Infantile (0 to 3 years); 2.) Juvenile (3 to 10 years); and 3.) Adolescent (age 11 and older, or from onset of puberty until skeletal maturity).

Scoliosis can be classified by etiology (cause): idiopathic (unkown cause), congenital (birth anomalies) or neuromuscular (nervous/muscle problem). Idiopathic scoliosis is the diagnosis when all other causes are excluded and comprises about 80 percent of all cases. Adolescent idiopathic scoliosis is the most common type of scoliosis and is usually diagnosed during puberty.

Congenital scoliosis:

Congenital scoliosis results from embryological malformation of one or more vertebrae and may occur in any location of the spine. The vertebral abnormalities cause curvature and other deformities of the spine because one area of the spinal column lengthens at a slower rate than the rest. The geometry and location of the abnormalities determine the rate at which the scoliosis progresses in magnitude as the child grows. Because these abnormalities are present at birth, congenital scoliosis is usually detected at a younger age than idiopathic scoliosis.

Neuromuscular scoliosis

Neuromuscular scoliosis encompasses scoliosis that is secondary to neurological or muscular diseases. This includes scoliosis associated with cerebral palsy, spinal cord trauma, muscular dystrophy, spinal muscular atrophy and spina bifida. This type of scoliosis generally progresses more rapidly than idiopathic scoliosis and often requires surgical treatment.

Early onset scoliosis can be congenital or neuromuscular or idiopathic variant and tend to affect boys more than girls. Late onset scoliosis is mostly Adolescent Idiopathic Scoliosis variant and tend to affects more girls than boys. There are several signs that may indicate the possibility of scoliosis. If one or more of the following signs is noticed, consult spine specialist.

  • Shoulders are uneven – one or both shoulder blades may stick out
  • Head is not centered directly above the pelvis
  • One or both hips are raised or unusually high
  • Rib cages are at different heights
  • Rib hump where ribs stick out unevenly
  • Waist is uneven
  • The appearance or texture of the skin overlying the spine changes (dimples, hairy patches, color abnormalities)
  • The entire body leans to one side

Scoliosis is usually confirmed through a physical examination and static and dynamic radiographs (X-rays). CT scan or MRI is done to assess bony or spinal cord abnormality as part of management plan. The curve is measured by the Cobb Method and is diagnosed in terms of severity by the number of degrees. A positive diagnosis of scoliosis is made based on a coronal curvature measured on a posterior-anterior radiograph of greater than 10 degrees. In general, a curve is considered significant if it is greater than 25 degrees. Curves exceeding 45 to 50 degrees are considered severe and often require more aggressive treatment.

A standard exam that is sometimes used by doctors and nurse is called the Adam’s Forward Bend Test. During this test, the patient leans forward with his or her feet together and bends 90 degrees at the waist. From this angle, any asymmetry of the trunk or any abnormal spinal curvatures can easily be detected by the examiner. This is a simple initial screening test that can detect potential problems, but cannot determine accurately the exact type or severity of the deformity. Radiographic tests are required for an accurate and positive diagnosis.

When there is a confirmed diagnosis of scoliosis, there are several issues to assess that can help determine treatment options:

  • Spinal maturity – is the patient’s spine still growing and changing?
  • Degree and extent of curvature – how severe is the curve and how does it affect the patient’s lifestyle?
  • Location of curve – according to some experts, thoracic curves are more likely to progress than curves in other regions of the spine.
  • Possibility of curve progression – patients who have large curves prior to their adolescent growth spurts are more likely to experience curve progression.

After these variables are assessed, treatment options recommended are observation, bracing or surgery.

Observation

In many children with scoliosis, the spinal curve is mild enough to not require treatment. However, if there is concern that curve would progress with time, then close monitoring of the child every four to six months throughout adolescence is considered.

Bracing

Braces are only effective in patients who have not reached skeletal maturity. If the child is still growing and his or her curve is between 25 degrees and 40 degrees, a brace may be recommended to prevent the curve from progressing. There have been improvements in brace design and the newer models fit under the arm, not around the neck. There are several different types of braces available. While there is some disagreement among experts as to which type of brace is most effective, large studies indicate that braces, when used with full compliance, successfully stop curve progression in about 75% percent of children with scoliosis. For optimal effectiveness, the brace should be checked regularly to assure a proper fit and may need to be worn 16 to 23 hours every day until growth stops.

Surgery

In children, the two primary goals of surgery are to stop the curve from progressing during adulthood and to correct spinal deformity. Most experts would recommend surgery only when the spinal curve is greater than 40 degrees and there are signs of progression. This surgery can be done using an anterior approach (through the front) or a posterior approach (through the back) depending on the particular case.

Posterior Scoliosis Correction and Fusion

The most frequently performed surgery for adolescent idiopathic scoliosis involves traditional posterior spinal fusion with instrumentation and bone grafting. This is performed through the back while the patient lies on his or her stomach. During this surgery, the spine is straightened with rigid rods, followed by spinal fusion. Spinal fusion involves adding a bone graft to the curved area of the spine, which creates a solid union between two or more vertebrae. The metal rods attached to the spine ensure that the backbone remains straight while the spinal fusion takes effect. This procedure usually takes several hours in children. With recent advances in technology, most people with idiopathic scoliosis are released from hospital within a week of surgery and do not require post-surgical bracing. Most patients are able to return to school or work in two to four weeks post surgery and are able to resume all pre-surgical activities within four to six months.

Anterior Scoliosis Correction and Fusion

Anterior Scoliosis correction and Fusion: The patient lies on his or her side during the surgery. The surgeon makes incisions in the patient’s side, deflates the lung and removes a rib in order to reach the spine. Video-assisted thoracoscopic (VAT) surgery offers enhanced visualization of the spine and is a less invasive surgery than an open procedure. The anterior spinal approach has several potential advantages: better deformity correction, quicker patient rehabilitation, improved spine mobilization and fusion of fewer segments. The potential disadvantages are that many patients require bracing for several months post surgery, and this approach has a higher risk of morbidity – although VAT has helped to reduce the latter.

In children with Early Onset or Congenital scoliosis, there is a known increased incidence of other congenital abnormalities. These are most commonly associated with the spinal cord (20 percent), the genitourinary system (20 to 33 percent) and the heart (10 to 15 percent). It is important that evaluation of the neurological, genitourinary and cardiovascular systems is undertaken when congenital scoliosis is diagnosed. Management of Early onset or congenital scoliosis is challenging and treatment has to commence at very early age to control the curve and allow spinal growth thereby allowing lung development and maturity. Casting, bracing and temporary growth rod distraction techniques are used with closed monitoring until the child attains reasonable skeletal maturity at which point definitive spinal fusion and scoliosis correction is considered.

Non Fusion/Dynamic Anterior Scoliosis Correction Surgery (Anterior Vertebral Body Tethering):

Over the past 100 years, significant advancements have been made in spinal fusion to treat scoliosis. These advancements have led to improved fusion rates, lower complication frequency, greater three-dimensional correction of the deformity and more rapid postoperative recovery. However, spine fusions mean fewer motion segments (less spine motion), which may lead to lower function in high-level physical activity (e.g. competitive athletics) and greater chance for spine arthritis. As a result, preservation of spinal motion, particularly in the low back, is an important goal.

The desire to maintain spine motion has fueled the development of various growth modulation procedures. The goals of these procedures are to correct the spinal deformity and maintain motion/flexibility (without fusion). One of these promising techniques that have gained traction in the last 10 years is vertebral body tethering (VBT). This technique uses the growth modulation principles where it places a compressive force over the convex side of the spine (slowing down growth) to permit the concave side of the spine to relatively grow more and create a straighter spine through remaining growth potential of the child. There is significant potential for this technology and early clinical results are promising but the technology is still under scrutiny and close monitoring.

Kyphosis

Kyphosis is a spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the back. The condition is sometimes known as “roundback” or in the case of a severe curve as “hunchback.” Kyphosis can occur at any age, but is common during adolescence.

Kyphosis is children can be due to Scheuermann’s disease, vertebral anomalies (birth defect) or infection (Tubercolosis, Kochs/Potts spine).

One particular type of kyphosis is Scheuermann’s kyphosis, also known as Scheuermann’s disease. Scheuermann’s kyphosis is characterized by wedge-shaped vertebrae that cause the thoracic spine to curve forward too much. Scheuermann’s kyphosis develops over time during periods of bone growth (such as puberty). It occurs when the front of the spine doesn’t grow as fast as the back of the spine and causes healthy, rectangular-shaped vertebrae to become triangular-shaped and wedged together. This causes the thoracic spine to curve more than normal. Patients become stooped forward with a bent-over posture. The exact causes of Scheuermann’s kyphosis are still unknown; however, researchers believe it has something to do with interrupted bone growth or an abnormality in how vertebrae develop and grow. This condition seems to run in families. Height and weight may also be contributing factors.

Kyphosis will present a stooped posture or slouching, rigid deformity, fatigue and back pain, neurological symptoms, and breathing difficulty because of impaired lung function in severe deformity.

Treatment options are observation, bracing or surgery

Observation and bracing are recommended if the curve or deformity is milder (40-70 degrees) and child has no associated pain or neurological symptoms.

Surgery is recommended when the deformity is severe (curve >70 degrees) or presenting neurological symptoms. Posterior correction and instrumented fusion is the standard surgical intervention.